Development and Pilot Evaluation of an e-Learning Module for Autologous Fat Transfer (AFT) in Total Breast Reconstruction in the Dutch Healthcare System: Insights From 9 Plastic Surgeons

Total breast reconstruction with autologous fat transfer (AFT) is a relatively new breast reconstruction method. Although AFT was predominantly used to correct postsurgical defects, the surgical skills of a total breast reconstruction with AFT are different and can be facilitated for novices to accelerate their learning process. This study aims to assess the learning curve of plastic surgeons in total breast reconstruction with AFT in the Netherlands. A mixed-methods study was performed based on the multicenter randomized clinical BREAST trial data. For the qualitative analysis, semistructured interviews were conducted. To test hypotheses derived from the qualitative data, retrospective data analysis was performed using multilevel linear regression analysis of the patients undergoing AFT as a total breast reconstruction method. The interviews revealed that plastic surgeons need to perform the procedure several times to learn and experience the technical details of total breast reconstruction with AFT. Learning and improving this technique works best by scrubbing in with an expert. Before plastic surgeons learn the optimal volume of fat reinjection over time, they tend to inject too little fat and subsequently too much fat over multiple procedures. With more experience, the rigottomy technique becomes more important. Besides technical details, managing patient expectations before starting treatment is paramount. Multilevel linear regression revealed a significant decrease ( P < 0.001) in the number of surgical procedures and the total injected volume ( P = 0.002) to complete a total breast reconstruction with AFT. This is the first study that explores the learning curve involved in using AFT as a total breast reconstruction method. The feeling of when fat transfer is sufficient, and how to release scars for a good result without causing seromas, is best learned by scrubbing in with experienced colleagues during several procedures, interchanged with starting one's own practice.

Autologous fat transfer (AFT) is an upcoming technique for total breast reconstruction. Consequently, radiological imaging of women with an AFT reconstructed breast will increase in the coming years, yet radiological experience and evidence after AFT is limited. The surgical procedure of AFT and follow-up with imaging modalities including mammography (MG), ultrasound (US), and MRI in patients with a total breast reconstruction with AFT are summarized to illustrate the radiological normal and suspicious findings for malignancy. Imaging after a total breast reconstruction with AFT appears to be based mostly on benign imaging findings with an overall low biopsy rate. As higher volumes are injected in this technique, the risk for the onset of fat necrosis increases. Imaging findings most often are related to fat necrosis after AFT. On MG, fat necrosis can mostly be seen as oil cysts. The occurrence of a breast seroma after total breast reconstruction with AFT is an unfavourable outcome and may require special treatment. Fat deposition in the pectoral muscle is a previously unknown, but benign entity. Although fat necrosis is a benign entity, it can mimic breast cancer (recurrence). In symptomatic women after total breast reconstruction with AFT, MG and US can be considered as first diagnostic modalities. Breast MRI can be used as a problem-solving tool during later stage. Future studies should investigate the most optimal follow-up strategy, including different imaging modalities, in patients treated with AFT for total breast reconstruction.

BackgroundAutologous fat transfer (AFT) is increasingly adopted as another total breast reconstruction option. The aim of this study is to investigate the efficacy of prolonged antibiotic treatment on the onset of surgical site infections in patients treated with AFT for total breast reconstruction. MethodsThis retrospective cohort study was conducted on patients who received AFT for total breast reconstruction, with antibiotic prophylaxis during their (multiple) AFT procedure(s) from 9 December 2020 to 10 October 2023. Patients were divided into two groups according to their prophylactic antibiotic regimen. The primary outcome was analysed as the cumulative incidence, the relative risk (RR), the absolute risk reduction (ARR), and the number needed to treat (NNT). For the secondary outcome, a multilevel logistic regression analysis was performed. Results765 surgeries in 205 patients were analyzed. 624 surgeries on 168 patients had perioperative antibiotic prophylaxis in combination with post-operative antibiotic prophylaxis was administered (group 1). 141 surgeries on 37 patients had only perioperative antibiotic prophylaxis administered (group 2). The RR was 0.68 (95%CI 0.14 – 3.31) of a surgical site infection (SSI) when receiving peri- and postoperative antibiotic prophylaxis in comparison to treatment with only perioperative prophylaxis. The ARR was 0.46% (95%CI -1.40 – 2.32) with a NNT of 219 patients. ConclusionProlonged antibiotic prophylaxis is ineffective for patients who receive total breast reconstruction with AFT. This study showed no statistically significant difference in SSIs of the reconstructed breast after receiving prolonged antibiotic treatment in comparison to single shot peri-operative antibiotic prophylaxis.

FigureAs a service to our readers, Plastic and Reconstructive Surgery® reviews books, DVDs, practice management software, and electronic media items of educational interest to reconstructive and aesthetic surgeons. All items are copyrighted and available commercially. The Journal actively solicits information in digital format (e.g., CD-ROM and Internet offerings) for review. Reviewers are selected on the basis of relevant interest. Reviews are solely the opinion of the reviewer; they are usually published as submitted, with only copy editing. Plastic and Reconstructive Surgery® does not endorse or recommend any review so published. Send books, DVDs, and any other material for consideration to: Ronald P. Gruber, M.D., Review Editor, Plastic and Reconstructive Surgery, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, POB1, Suite 300, Dallas, Texas 75390-8820. Although the concept of fat grafting in plastic surgery is over a century old, enthusiasm for its use in aesthetic and reconstructive surgery of the breasts has gained momentum over the past decade. Drs. Khouri and Biggs have made significant contributions to understanding and refining techniques for fat transfer to the breasts. They have extensively described Brava (Brava, LLC, Miami, Fla.) and autologous fat transfer for breast augmentation and reconstruction and have accumulated significant experience with their technique. In Your Natural Breasts: A Better Way to Augment, Reconstruct, and Correct Using Your Own Fat, Drs. Khouri and Biggs outline their concepts, technique, and outcomes using Brava and autologous fat transfer. The book is divided into three sections. The first section provides a history of fat transfer to the breasts, outlines concepts for Brava and autologous fat transfer, compares Brava and autologous fat transfer with traditional techniques, and discusses some potential challenges with Brava and autologous fat transfer. In the second section, the applications for Brava and autologous fat transfer for cosmetic breast reconstruction are presented, and in the third section, the applications for Brava and autologous fat transfer for breast cancer reconstruction are outlined. This book contains many before-and-after photographs showing results following Brava and autologous fat transfer. These results are a testament to the versatility of this technique. What is particularly impressive are the results shown in Chapters 16 and 17 describing the use of Brava and autologous fat transfer for salvage reconstructions after failed implant and flap reconstructions. In these challenging cases, I do not know whether it is possible to achieve the results that are shown by any other approach for breast reconstruction. The results in Chapter 10 are equally impressive; correction of developmental deformities, including tuberous breasts, is shown. This book is well suited for patients who are interested in finding out more information about breast reconstruction and the option of Brava and autologous fat transfer. The authors have made a conscious effort to discuss the information in a way that is easy for patients to understand. There are many patient stories throughout the book—these provide patients’ perspective on their journey and will help to not only inform prospective patients but also reassure them that there is hope. For the plastic surgeon performing aesthetic and reconstructive surgery of the breast using Brava and autologous fat transfer, this book would be very useful to help inform patients about this technique and prepare them for this surgery. In summary, Your Natural Breasts: A Better Way to Augment, Reconstruct, and Correct Using Your Own Fat, will be useful to both patients considering breast reconstruction and plastic surgeons performing Brava and autologous fat transfer.

BACKGROUND: Autologous Fat transfer (AFT) is now widely accepted as an adjunct to traditional methods of breast reconstruction. However, AFT’s ability to reconstruct an entire breast is not yet firmly established. We hereby present our seven-year, multicenter experience with total breast reconstruction using solely AFT and external expansion. METHODS: We performed 1,877 AFT procedures on 616 breasts in 488 women (44% radiated) to reconstruct 99 lumpectomies, 87 immediate, and 430 delayed total breast reconstructions. Effective graft retention requires the fat to be delivered as micro-ribbons to enhance surface area-to-volume ratio and oxygen delivery, the interstitial fluid pressure (IFP) to remain below 9 mmHg to prevent reduced perfusion, and the recipient site to have sufficient vascularity.1,2 To optimize these variables, after 2-4 weeks of Brava treatment, which increased pre-expansion volume by 100-300%, we diffusely injected the breasts with 100-400 ml (225 ml, average) of micro-droplets of 15G sedimented, manually harvested lipoaspirate.3 For patients with restrictive scarring, the Percutaneous Aponeurotomy and Lipo-Filling (PALF) technique was used.4 The procedure was repeated every 8-14 weeks as needed till completion of the reconstruction. Follow up ranges from six months to seven years (mean, 2.5 years). 427 women completed the reconstruction, while 12.5% dropped out (2.5% medical, 10% personal reasons). RESULTS: Final breast reconstructed volume was 375 ml (150–900). Completing the reconstruction required 2.0, 2.1, 2.8, 4.2, and 4.9 procedures/breast for lumpectomy, nonradiated immediate, nonradiated delayed, radiated immediate, and radiated delayed mastectomies, respectively. 97% were satisfied with the volume, shape, and feel of their breasts as they recovered near-normal sensation over the entire mound. 37% of the radiated and 12% of the nonradiated reconstructions had palpable masses, none of which required open biopsy. Complications included 5 (0.8%) pneumothoraces, 15 (2.4%) abscesses/ulcerations in the radiated, and 3 (0.5%) abscesses/ulcerations in the nonradiated breasts. The immediate nonradiated had the best results, while the immediate radiated had the highest complications. One mastectomy (0.2%) and two lumpectomies (2.0%) had local recurrence. As has been reported in other large studies on fat grafting the breast,5 we found no increased rate of cancer recurrence (Figures 1 and 2).Figure 1: 42-year-old woman two years after a bilateral mastectomy.Figure 2: After three Brava + AFT procedures and a nipple reconstruction, she regenerated her >600 ml breasts and improved her body contour without any incisions.CONCLUSIONS: AFT + Brava is a minimally invasive, safe, and effective alternative for breast reconstruction. The procedure is outpatient, involves no incision, has minimal complications, and a very high level of patient satisfaction.

Preliminary data on the oncological safety of autologous fat transfer (AFT) for total breast reconstruction from the BREAST trial.

50 - Total breast reconstruction by external vacuum expansion (EVE) and autologous fat transfer (AFT)

Objective: Total autologous breast reconstruction is traditionally performed using large volume flaps that often involve underlying muscle. Perforator flaps are based on a skin perforator and spare the muscle, however, the use of local perforator flaps in total breast reconstruction has not been documented. The objective of this study was to provide a single surgeon’s experience using lateral chest wall perforator flaps with large volume fat grafting in delayed total breast reconstruction. Methods: A retrospective analysis was conducted of all consecutive total breast reconstructive procedures utilizing lateral chest wall perforator flaps and/or fat grafting performed between October 2015 and October 2021. Results: Twenty-three patients underwent 43 breast reconstructions, 39 of which utilized lateral chest wall perforator flaps. Indications for surgery included the following: absence of breast, implant loss due to infection, desire for autologous reconstruction, implant rupture, capsular contracture, massive weight loss, and lumpectomy. Most patients (87.0%) did not require hospitalization. Two patients who underwent concurrent contralateral latissimus dorsi flap reconstruction were admitted. One patient after perforator flap reconstruction experienced a cardiovascular event which resulted in a stay of 32 hours. The most common complication requiring medical intervention was fat necrosis which occurred in 15 perforator flap reconstructed breasts (38.5%). The majority of fat necrosis resolved without operative intervention but necessitated drainage in 11 breasts (73%), massage (3/15, 20%), or physical therapy (1/15, 6.7%), and only one breast required excision (6.7%). Patients who experienced fat necrosis had a significantly higher BMI than patients without fat necrosis (33±6 vs 28±4, p = 0.039). Additionally, fat necrosis occurred in breasts that had a higher average volume of fat grafting (248 vs 154; p = 0.0027). Additional complications experienced by patients included surgical site infection (n = 7; 17.9%), wound dehiscence (n = 7; 17.9%), seroma (n = 5; 12.8%), and flap necrosis (n = 2; 5.1%). Conclusion: Our study demonstrates that lateral chest wall perforator flaps can be extended to total breast reconstruction when performed concurrently with large volume fat grafting. This novel approach can be utilized safely as an outpatient procedure with the most frequent complication being fat necrosis; a complication associated with higher BMI and fat grafting volume. Corresponding Author: Darin Patmon, 4254 Oak Forest Ct. SE Apt H8, Grand Rapids, MI 49546

Introduction and importanceTotal breast reconstruction with autologous fat transfer (AFT) has a low complication rate. Fat necrosis, infection, skin necrosis and hematoma are the most common complications. Infections are usually mild and manifested by a unilateral red painful breast and treated with oral antibiotics with or without superficial irrigation of the wound.Case presentationOne of our patients reported an ill-fitting pre-expansion device several days after surgery. This was due to a severe bilateral breast infection following a session of total breast reconstruction with AFT despite perioperative and postoperative antibiotic prophylaxis. Surgical evacuation was performed in combination with both systemic and oral antibiotic treatment.Clinical discussionMost infections can be prevented in the early post-operative period with antibiotic prophylaxis. If an infection does occur, it is treated with antibiotics or superficial irrigation of the wound. A delay in identification of an alarming course could be reduced by monitoring the fit to the EVEBRA device, implementing video consultations on indication, limiting the means of communication and better informing the patient on what complications to monitor. The recognition of an alarming course following a subsequent session of AFT is not guaranteed after a session without complication.ConclusionBesides temperature and redness of the breast, a pre-expansion device that doesn't fit can be an alarming sign. Patient communication should be adapted as severe infections can be insufficiently recognized by phone. Evacuation should be considered when an infection does occur.

Spotlight in Plastic Surgery: April 2020

Autologous fat transfer has an important role in breast reconstructive surgery. Nevertheless, some concerns remain with regard to its oncologic safety. The authors present a single-center, case-matching study analyzing the impact of autologous fat transfer in the cumulative incidence of local recurrences. From a prospectively maintained database, the authors identified 902 patients who underwent 1025 breast reconstructions from 2005 to 2017. Data regarding demographics, tumor characteristics, surgery details, and follow-up were collected. Exclusion criteria were patients with distant metastases at diagnosis, recurrent tumor, or incomplete data regarding primary tumor; and patients who underwent prophylactic mastectomies and breast-conserving operations. Statistical analysis was conducted to evaluate the impact of the variables on the incidence of local recurrence. A value of p < 0.05 was considered statistically significant. After 1: n case-matching, we selected 919 breasts, of which 425 patients (46.2 percent) received at least one autologous fat transfer session versus 494 control cases (53.8 percent). Local recurrences had an overall rate of 6.8 percent, and we found local recurrences in 14 autologous fat transfer cases (3.0 percent) and 54 controls (9.6 percent). Statistical analysis showed that autologous fat transfer did not increase the risk of local recurrences (hazard ratio, 0.337; CI, 0.173 to 0.658; p = 0.00007). Multivariate analysis identified invasive ductal carcinoma subtype and lymph node metastases to have an increased risk of local recurrences (hazard ratio >1). Conversely, positive hormonal receptor status was associated with a reduced risk of events (hazard ratio <1). Autologous fat transfer was not associated with a higher probability of locoregional recurrence in patients undergoing breast reconstruction; therefore, it can be safely used for total breast reconstruction or aesthetic refinements. Risk, II.

BackgroundAutologous fat transfer (AFT) seems to be a new minimal invasive method for total breast reconstruction, yet how patients, surgeons, and laymen evaluate cosmesis is lacking. The aim of this study was to evaluate the aesthetic outcome of AFT (intervention group) for total breast reconstruction post-mastectomy, as compared to implant-based reconstruction (IBR) (control group).MethodsA random and blinded 3D photographic aesthetic outcome study was performed on a selection of 50 patients, scored by three panels: plastic surgeons, breast cancer patients, and laymen. Secondary outcomes included agreement within groups and possible patient characteristics influencing scoring.ResultsBreast cancer patients and plastic surgeons did not differ in the aesthetic scores between the treatment groups. In contrast, the laymen group scored AFT patients lower than IBR patients (− 1.04, p < 0.001). Remarkably, mean given scores were low for all groups and overall agreement within groups was poor (ICC < 0.50). Higher scores were given when subjects underwent a bilateral reconstruction and if a mamilla was present.ConclusionEvaluation of aesthetic outcomes varies greatly. Hence, aesthetic outcome remains a very personal measure and this emphasizes the importance of thorough patient counseling including information on achievable aesthetic results before starting a reconstructive procedure.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Fourth World Congress of the International Society of Plastic Regenerative Surgeons: Another Successful Scientific Forum for Regenerative Surgery.

Aesthetic results were more satisfactory after oncoplastic surgery than after total breast reconstruction according to patients and surgeons.

PURPOSE: Autologous reconstructions provide long-term patient satisfaction but are in-patient invasive procedures with morbidities and complications. AFT alone reconstructions are limited because fat is not an expander. Pre-expansion of the mastectomy followed by AFT to the laxity created by RE solves this limitation. METHODS: For immediate reconstructions, we insert subpectoral expanders and graft 150-200ml as fat ribbons teased in-between the exposed muscle fibers. After adequate post-operative expansion, we remove the expander, graft the laxity with 250-350ml of fat, and preserve the breast mound by inserting an implant half the expander size. To convert the implant reconstructed breasts to autologous fat, we remove the implant, replace it with a 50% smaller one and graft the loosened tissues. In both situations we repeat the procedure every three months till the patient is implant free. RESULTS: We reviewed our past 2000 consecutive AFT-ER out-patient breasts reconstructions. Non-radiated mastectomies required 3.2 sessions. At each session, the expanded breast volume remained constant as the intervening mastectomy tissue thickness doubled while the implant volume halved. Radiated breasts took 5.8 sessions, with less grafting per session and less than halving implant size. Patient satisfaction was very high, especially in previously implant reconstructed patients converted to fat. Complications were minimal, more frequent in the radiated breasts and mostly due to overgrafting or excessive scar release in cases with previous complications. CONCLUSION: AFT-ER is a safe and highly satisfying autologous breast reconstruction alternative with no donor site defect and liposuction bonus. The multiple procedures are minimally invasive and out-patient.